How to Measure Costs and Benefits of eHealth Interventions: An Overview of Methods and Frameworks

Appraising eHealth Investment for Africa: Scoping Review and Development of a Framework

BACKGROUND

As opportunities grow for resource-constrained countries to use eHealth (digital health) to strengthen health systems, a dilemma arises. Wise eHealth investments require adequate appraisal to address opportunity costs. Economic appraisal techniques conventionally utilised for this purpose require sufficient economic expertise and adequate data that are frequently in short supply in low- and middle-income countries. This paper aims to identify, and, if required, develop, a suitable framework for performing eHealth investment appraisals in settings of limited economic expertise and data.

METHODS

Four progressive steps were followed: (1) identify required framework attributes from published checklists; (2) select, review, and chart relevant frameworks using a scoping review; (3) analyse the frameworks using deductive and inductive iterations; and, if necessary, (4) develop a new framework using findings from the first three steps.

RESULTS

Twenty-four candidate investment appraisal attributes were identified and seven relevant frameworks were selected for review. Analysis of these frameworks led to the refinement of the candidate attributes to 23 final attributes, and each framework was compared against them. No individual framework adequately addressed sufficient attributes. A new framework was developed that addressed all 23 final attributes.

CONCLUSIONS

A new evidence-based investment appraisal framework has been developed that provides a practical, business case focus for use in resource-constrained African settings.

User-Centered Design and Usability of Voxe as a Pediatric Electronic Patient-Reported Outcome Measure Platform: Mixed Methods Evaluation Study

BACKGROUND

Electronic patient-reported outcome measures (ePROMs) are standardized digital instruments integrated into clinical care to collect subjective data regarding patients' health-related quality of life, functional status, and symptoms. In documenting patient-reported progress, ePROMs can guide treatment decisions and encourage measurement-based care practices. Voxe is a pediatric and user-centered ePROM platform for patients with chronic health conditions.

OBJECTIVE

We aimed to describe the user-centered design approach involving feedback from end users and usability testing of Voxe's platform features to support implementation in a pediatric health care setting.

METHODS

Purposive sampling was used to recruit patients aged 8-17 years from 2 chronic illness populations in 2 pediatric hospitals in Canada. Patients' health care team members were also purposively recruited. One-on-one iterative testing sessions were conducted digitally by research team members with participants to obtain feedback on the appearance and functionalities of the Voxe platform prototype. Patients and health care providers (HCPs) completed Voxe-related task-based activities. International Organization for Standardization key performance indicators were tracked during HCP task-based activities. HCPs also completed the System Usability Scale. To test platform usability, the think-aloud technique was used by participants during the completion of structured tasks. After completing all task-based activities, patient participants selected 5 words from the Microsoft Desirability Toolkit to describe their overall impression and experience with the Voxe platform. Qualitative data about likes, dislikes, and ease of use were collected through semistructured interviews. Feedback testing sessions were conducted with patients and HCPs until Voxe was acceptable to participating end users, with no further refinements identified. Quantitative and qualitative data analysis were completed using descriptive statistics and content analysis.

RESULTS

A total of 49 patients and 38 HCPs were recruited. Patients were positive about Voxe's child-centered design characteristics and notification settings. HCPs rated Voxe as user-friendly and efficient, with the time to complete tasks decreasing over time. HCPs were satisfied with the Voxe platform functionalities and identified the value of Voxe's system notifications, summarized display of ePROM results, and its capacity to integrate with electronic medical records. Patients' and HCPs' high satisfaction rates with the Voxe prototype highlight the importance of being responsive to user suggestions from the inception of eHealth platform developments to ensure their efficient and effective design.

CONCLUSIONS

This paper describes the user-centered creation and usability testing of Voxe as an ePROM platform for implementation into clinical care for pediatric patients with chronic health conditions. As a patient-facing platform that can be integrated into electronic medical records, Voxe aligns with measurement-based care practices to foster quality patient-centered approaches to care. End users' positive feedback and evaluation of the platform's user-friendliness and efficiency suggest that Voxe represents a valuable and promising solution to systematically integrate patient-related outcome (PRO) data into complex and dynamic clinical health care settings.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2021-053119.

Cost-effectiveness analysis of app-delivered self-management support (selfBACK) in addition to usual care for people with low back pain in Denmark

OBJECTIVES

This study aims to investigate the cost-effectiveness of individually tailored self-management support, delivered via the artificial intelligence-based selfBACK app, as an add-on to usual care for people with low back pain (LBP).

DESIGN

Secondary health-economic analysis of the selfBACK randomised controlled trial (RCT) with a 9-month follow-up conducted from a Danish national healthcare perspective (primary scenario) and a societal perspective limited to long-term productivity in the form of long-term absenteeism (secondary scenario).

SETTING

Primary care and an outpatient spine clinic in Denmark.

PARTICIPANTS

A subset of Danish participants in the selfBACK RCT, including 297 adults with LBP randomised to the intervention (n=148) or the control group (n=149).

INTERVENTIONS

App-delivered evidence-based, individually tailored self-management support as an add-on to usual care compared with usual care alone among people with LBP.

OUTCOME MEASURES

Costs of healthcare usage and productivity loss, quality-adjusted life-years (QALYs) based on the EuroQol-5L Dimension Questionnaire, meaningful changes in LBP-related disability measured by the Roland-Morris Disability Questionnaire (RMDQ) and the Pain Self-Efficacy Questionnaire (PSEQ), costs (healthcare and productivity loss measured in Euro) and incremental cost-effectiveness ratios (ICERs).

RESULTS

The incremental costs were higher for the selfBACK intervention (mean difference €230 (95% CI -136 to 595)), where ICERs showed an increase in costs of €7336 per QALY gained in the intervention group, and €1302 and €1634 for an additional person with minimal important change on the PSEQ and RMDQ score, respectively. At a cost-effectiveness threshold value of €23250, the selfBACK intervention has a 98% probability of being cost-effective. Analysis of productivity loss was very sensitive, which creates uncertainty about the results from a societal perspective limited to long-term productivity.

CONCLUSIONS

From a healthcare perspective, the selfBACK intervention is likely to represent a cost-effective treatment for people with LBP. However, including productivity loss introduces uncertainty to the results.

TRIAL REGISTRATION NUMBER

NCT03798288.

Connected and supported: a scoping review of how online communities provide social support for breast cancer survivors

PURPOSE

To (i) assess how and to what extent online communities are used among breast cancer survivors (BCS) as a source of social support, (ii) describe the kind of support BCS access through online communities, and (iii) explore how these communities foster social support for BCS that promotes well-being and reduces the challenges of survivorship.

METHODS

We conducted a scoping review. A professional librarian performed a comprehensive search in multiple databases from January 2010 to May 2023. The review process adhered to the Johana Briggs Institute's method guidelines and the PRISMA-ScR reporting system.

RESULTS

Fifteen studies were included. Participants used social media, cancer support communities, message boards, or websites for information and emotional support. Qualitative findings resulted in four themes: to reassure; to empower; to promote equity, diversity, and inclusion; and to demonstrate for BCS the drawbacks of online support.

CONCLUSIONS

We underscore that a variety of internet websites and social media platforms are valuable for and appreciated by BCS, especially as a source of social support and human connectedness. Our study raises the existing gap in cultural/ethnic representation in this field and shows that institutional and organizational efforts are needed to address gaps in information regarding access to social support for multiethnic BCS women.

IMPLICATIONS FOR CANCER SURVIVORS

This data synthesis will empower the BCS community by sharing how they can strengthen and support their peers and community via their participation in online communities that connect and support cancer survivors in healthcare spaces.

Evaluating Artificial Intelligence in Clinical Settings-Let Us Not Reinvent the Wheel

Given the requirement to minimize the risks and maximize the benefits of technology applications in health care provision, there is an urgent need to incorporate theory-informed health IT (HIT) evaluation frameworks into existing and emerging guidelines for the evaluation of artificial intelligence (AI). Such frameworks can help developers, implementers, and strategic decision makers to build on experience and the existing empirical evidence base. We provide a pragmatic conceptual overview of selected concrete examples of how existing theory-informed HIT evaluation frameworks may be used to inform the safe development and implementation of AI in health care settings. The list is not exhaustive and is intended to illustrate applications in line with various stakeholder requirements. Existing HIT evaluation frameworks can help to inform AI-based development and implementation by supporting developers and strategic decision makers in considering relevant technology, user, and organizational dimensions. This can facilitate the design of technologies, their implementation in user and organizational settings, and the sustainability and scalability of technologies.

Can we increase the value of data from bladder diaries? International Consultation on Incontinence-Research Society 2023

BACKGROUND

Bladder diaries represent a fundamental component in the assessment of patients presenting with lower urinary tract symptoms. Nevertheless, their importance often remains underappreciated and undervalued within clinical practice. This paper aims to conduct a comprehensive review of the existing literature concerning the utility of bladder diaries, underscore the criticality of their precision, elucidate the factors contributing to noncompliance with bladder diary completion, and investigate potential strategies for enhancing patient compliance.

MATERIALS AND METHODS

A review of the English-language scientific literature available in the domains of Medline, Embase, Emcare, Midirs, and Cinahl was conducted. This was supplemented by discussion at the International Consultation on Incontinence Research Society Proposal session to define knowledge and identify gaps in knowledge surrounding the utility of bladder diaries. The existing evidence and outcome of the relevant discussion held in the meeting are presented.

RESULTS

Bladder diaries (BD) serve to characterize the nature and severity of storage lower urinary tract symptoms (LUTS) and provide an objective record of an individual's urination patterns. They aid in the refinement and customization of treatment strategies based on the clinical responses documented in the diary, optimizing treatment outcomes. Notably, both BD and urodynamic studies (UDS) play complementary yet distinct roles in LUTS evaluation. BD offers a more comprehensive and accessible approach to assessing specific storage LUTS, particularly due to their affordability and widespread availability, especially in resource-limited settings. Nevertheless, the absence of a standardized BD format across global healthcare systems presents a significant challenge. Despite being recognized as reliable, noninvasive, validated, and cost-effective tools for evaluating patients with LUTS, the implementation and completion of BD have proven to be complex. The introduction of automated bladder diaries heralds an era of precise, real-time data collection, potentially enhancing the patient-clinician relationship. Completion of bladder diaries depends on an array of individual, social, and healthcare-specific factors. Compliance with bladder diary completion could be enhanced with clear instructions, patient education, regular follow-ups and positive re-enforcement. This study has identified four critical areas for future research: Addressing healthcare disparities between affluent and developing nations, enhancing the current functionality and effectiveness of bladder diaries, exploring the feasibility of incorporating bladder diaries into the treatment and education process and improving the quality and functionality of existing bladder diaries.

CONCLUSION

Bladder diaries play a pivotal role in the evaluation and management of patients with LUTS, providing a holistic perspective. When their complete potential is harnessed, they have the capacity to revolutionize the paradigm of LUTS management, ushering in a patient-centered era of care.

Economic impact of outpatient follow-up using telemedicine vs in-person visits for patients in general surgery: A secondary analysis of a randomized clinical trial

INTRODUCTION

Innovation in internet connectivity and the Covid 19 pandemic have caused a dramatic change in the management of patients in the medical field, boosting the use of telemedicine. A comparison of clinical outcomes and satisfaction between conventional face-to-face and telemedicine follow-up in general surgery, an economic evaluation is mandatory. The aim of the present study was to compare the differences in economic costs between these two outpatient approaches in a designed randomized controlled trial (RCT).

METHODS

A RCT was conducted enrolling 200 patients to compare conventional in-person vs. digital health follow-up using telemedicine in the outpatient clinics in patients of General Surgery Department after their planned discharge. After a demonstration that no differences were found in clinical outcomes and patient satisfaction, we analyzed the medical costs, including staff wages, initial investment, patent's transportation and impact on social costs.

RESULTS

After an initial investment of 7527.53€, the costs for the Medical institution of in-person conventional follow-up were higher (8180.4€) than those using telemedicine (4630.06€). In relation to social costs, loss of productivity was also increased in the conventional follow-up.

CONCLUSION

The use of digital Health telemedicine is a cost-effective approach compared to conventional face-to-face follow-up in patients of General Surgery after hospital discharge.

Developing a Program Costs Checklist of Digital Health Interventions: A Scoping Review and Empirical Case Study

INTRODUCTION

The rate of development and complexity of digital health interventions (DHIs) in recent years has to some extent outpaced the methodological development in economic evaluation and costing. Particularly, the choice of cost components included in intervention or program costs of DHIs have received scant attention. The aim of this study was to build a literature-informed checklist of program cost components of DHIs. The checklist was next tested by applying it to an empirical case, Mamma Mia, a DHI developed to prevent perinatal depression.

METHOD

A scoping review with a structured literature search identified peer-reviewed literature from 2010 to 2022 that offers guidance on program costs of DHIs. Relevant guidance was summarized and extracted elements were organized into categories of main cost components and their associated activities following the standard three-step approach, that is, activities, resource use and unit costs.

RESULTS

Of the 3448 records reviewed, 12 studies met the criteria for data extraction. The main cost categories identified were development, research, maintenance, implementation and health personnel involvement (HPI). Costs are largely considered to be context-specific, may decrease as the DHI matures and vary with number of users. The five categories and their associated activities constitute the checklist. This was applied to estimate program costs per user for Mamma Mia Self-Guided and Blended, the latter including additional guidance from public health nurses during standard maternal check-ups. Excluding research, the program cost per mother was more than double for Blended compared with Self-Guided (€140.5 versus €56.6, 2022 Euros) due to increased implementation and HPI costs. Including research increased the program costs to €190.8 and €106.9, respectively. One-way sensitivity analyses showed sensitivity to changes in number of users, lifespan of the app, salaries and license fee.

CONCLUSION

The checklist can help increase transparency of cost calculation and improve future comparison across studies.

Methodological Frameworks and Dimensions to Be Considered in Digital Health Technology Assessment: Scoping Review and Thematic Analysis

BACKGROUND

Digital health technologies (dHTs) offer a unique opportunity to address some of the major challenges facing health care systems worldwide. However, the implementation of dHTs raises some concerns, such as the limited understanding of their real impact on health systems and people's well-being or the potential risks derived from their use. In this context, health technology assessment (HTA) is 1 of the main tools that health systems can use to appraise evidence and determine the value of a given dHT. Nevertheless, due to the nature of dHTs, experts highlight the need to reconsider the frameworks used in traditional HTA.

OBJECTIVE

This scoping review (ScR) aimed to identify the methodological frameworks used worldwide for digital health technology assessment (dHTA); determine what domains are being considered; and generate, through a thematic analysis, a proposal for a methodological framework based on the most frequently described domains in the literature.

METHODS

The ScR was performed in accordance with the guidelines established in the PRISMA-ScR guidelines. We searched 7 databases for peer reviews and gray literature published between January 2011 and December 2021. The retrieved studies were screened using Rayyan in a single-blind manner by 2 independent authors, and data were extracted using ATLAS.ti software. The same software was used for thematic analysis.

RESULTS

The systematic search retrieved 3061 studies (n=2238, 73.1%, unique), of which 26 (0.8%) studies were included. From these, we identified 102 methodological frameworks designed for dHTA. These frameworks revealed great heterogeneity between them due to their different structures, approaches, and items to be considered in dHTA. In addition, we identified different wording used to refer to similar concepts. Through thematic analysis, we reduced this heterogeneity. In the first phase of the analysis, 176 provisional codes related to different assessment items emerged. In the second phase, these codes were clustered into 86 descriptive themes, which, in turn, were grouped in the third phase into 61 analytical themes and organized through a vertical hierarchy of 3 levels: level 1 formed by 13 domains, level 2 formed by 38 dimensions, and level 3 formed by 11 subdimensions. From these 61 analytical themes, we developed a proposal for a methodological framework for dHTA.

CONCLUSIONS

There is a need to adapt the existing frameworks used for dHTA or create new ones to more comprehensively assess different kinds of dHTs. Through this ScR, we identified 26 studies including 102 methodological frameworks and tools for dHTA. The thematic analysis of those 26 studies led to the definition of 12 domains, 38 dimensions, and 11 subdimensions that should be considered in dHTA.

Increasing access to mental health supports for 12-17-year-old Indigenous youth with the JoyPop mobile mental health app: study protocol for a randomized controlled trial

BACKGROUND

Indigenous youth in Northwestern Ontario who need mental health supports experience longer waits than non-Indigenous youth within the region and when compared to youth in urban areas. Limited access and extended waits can exacerbate symptoms, prolong distress, and increase risk for adverse outcomes. Innovative approaches are urgently needed to provide support for Indigenous youth in Northwestern Ontario. Using a randomized controlled trial design, the primary objective of this study is to determine the effectiveness of the JoyPop app compared to usual practice (UP; monitoring) in improving emotion regulation among Indigenous youth (12-17 years) who are awaiting mental health services. The secondary objectives are to (1) assess change in mental health difficulties and treatment readiness between youth in each condition to better understand the app's broader impact as a waitlist tool and (2) conduct an economic analysis to determine whether receiving the app while waiting for mental health services reduces other health service use and associated costs.

METHODS

A pragmatic, parallel arm randomized controlled superiority trial will be used. Participants will be randomly allocated in a 1:1 ratio to the control (UP) or intervention (UP + JoyPop) condition. Stratified block randomization will be used to randomly assign participants to each condition. All participants will be monitored through existing waitlist practices, which involve regular phone calls to check in and assess functioning. Participants in the intervention condition will receive access to the JoyPop app for 4 weeks and will be asked to use it at least twice daily. All participants will be asked to complete outcome measures at baseline, after 2 weeks, and after 4 weeks.

DISCUSSION

This trial will evaluate the effectiveness of the JoyPop app as a tool to support Indigenous youth waiting for mental health services. Should findings show that using the JoyPop app is beneficial, there may be support from partners and other organizations to integrate it into usual care pathways.

TRIAL REGISTRATION

https://clinicaltrials.gov/study/NCT05898516 [registered on June 1, 2023].

Telehealth Transformation: A Mixed-Methods Study on Organizational Change Processes and Outcomes in a Private Medical Practice

BACKGROUND

 This mixed-methods case study investigated the impacts, costs, barriers, and facilitators associated with implementing telehealth services across a private pediatric clinic system. The research examined the effects of telehealth on provider engagement and financial performance.

METHODOLOGY

 Twenty-three clinicians, administrators, and staff across the pediatric clinics were interviewed before and after enterprise-level telehealth adoption to examine change processes amid this innovation. Twelve months of pre- and post-implementation financial records underwent statistical analysis to assess revenue and cost dynamics. Quantitative outcome measures encompassed expenses, revenues, and telehealth visit utilization rates, while qualitative analysis of interviews and focus groups revealed key implementation themes through rigorous inductive coding of participant narratives.

RESULTS

Results showed significantly increased costs (44%) and revenues (47%) at clinics following virtual care expansion. Monthly telehealth visits per provider exponentially rose over 450%. Qualitatively, 83% of providers appreciated scheduling flexibility benefits, but 68% of staff cited workflow disruptions.

CONCLUSIONS

Interpretatively, findings demonstrated catalyzed financial and productivity transformations and nuanced perceived disruption amid pronounced appointment capacity expansions. Recommendations encompass updated care coordination protocols, enhanced training and support resources, incentivizing provider usage, and modulating implementation pacing responding to user feedback during large-scale organizational innovation.

Telehealth Consultation for Malaysian Citizens' Willingness to Pay Assessed by the Double-Bounded Dichotomous Choice Method

Background

Re-envisioning healthcare in technology tools includes robust utilisation of telehealth, improvement in access, quality, care efficiencies and cost-effectiveness of healthcare services. In reality, the technology's potential to transform healthcare may be limited by the ability to pay for it. This study aims to estimate Malaysian citizens' willingness to pay (WTP) for telehealth consultations and determine the factors contributing to it. This is vital to inform decision-making about expansion, preferences and deployment of a pricing strategy for telehealth services.

Methods

A random sample of 220 adult Malaysians was surveyed using social network services (SNS). Three different WTP bid arrays were identified and each respondent received a randomly drawn bid price. The WTP fee for using the telehealth consultation for 30 min was measured and estimated using a Double-Bounded Dichotomous Choice (DBDC) and the Random Utility Logit Model.

Result

The median WTP was estimated to be RM58 (JPY2,198), RM78 (JPY2,956) for 132 respondents' willingness to use telehealth consultation and RM26 (JPY985) for 51 respondents who were unwilling. Further analysis found that WTP is correlated with the perception and willingness of the respondents to use it.

Conclusion

Despite most respondents being willing to pay for telehealth consultations, sociodemographic characteristics and affordability influenced the process of making decisions about WTP for telehealth consultation. This finding suggests that the private sector can play a crucial role in the deployment of telehealth. However, there may be a need to consider affordability and how to increase access and use of telehealth services.

Physical activity with person-centered guidance supported by a digital platform or with telephone follow-up for persons with chronic widespread pain: Health economic considerations along a randomized controlled trial

OBJECTIVES

The aim was to investigate the resource use and costs associated with the co-creation of a physical activity plan for persons with chronic widespread pain (CWP) followed by support through a digital platform, compared to telephone follow-up.

METHODS

In this 12-month cost comparison study following up results after a randomized controlled trial, individuals with CWP, aged 20-65 years, were recruited at primary healthcare units in Western Sweden. All participants developed a person-centered health-enhancing physical activity plan together with a physiotherapist. Participants were then randomized to either an intervention group (n  =  69) who had a follow-up visit after 2 weeks and was thereafter supported through a digital platform, or an active control group (n  =  70) that was followed up through one phone call after a month. Costs to the health system were salary costs for the time recorded by physiotherapists when delivering the interventions.

RESULTS

The reported time per person (2.8 h during the 12 months) corresponded to costs of SEK 958 (range: 746-1,517) for the initial visits and follow-up (both study groups), and an additional 2.5 h (corresponding to a mean SEK 833; range: 636-1,257) for the time spent in the digital platform to support the intervention group.

CONCLUSION

After co-creation of a physical activity plan, it was more costly to support persons through a digital platform, compared to telephone follow-up.

Digitization of Follow-Up Care in Orthopedic and Trauma Surgery With Video Consultations: Health Economic Evaluation Study From a Health Provider's Perspective

BACKGROUND

Recommendations for health care digitization as issued with the Riyadh Declaration led to an uptake in telemedicine to cope with the COVID-19 pandemic. Evaluations based on clinical data are needed to support stakeholders' decision-making on the long-term implementation of digital health.

OBJECTIVE

This health economic evaluation aims to provide the first German analysis of the suitability of video consultations in the follow-up care of patients in orthopedic and trauma surgery, investigate the financial impact on hospital operations and personnel costs, and provide a basis for decisions on digitizing outpatient care.

METHODS

We conducted a randomized controlled trial that evaluated video consultations versus face-to-face consultations in the follow-up care of patients in orthopedic and trauma surgery at a German university hospital. We recruited 60 patients who had previously been treated conservatively or surgically for various knee or shoulder injuries. A digital health app and a browser-based software were used to conduct video consultations. The suitability of telemedicine was assessed using the Telemedicine Satisfaction Questionnaire and the EQ-5D-5L questionnaire. Economic analyses included average time spent by physician per consultation, associated personnel costs and capacities for additional treatable patients, and the break-even point for video consultation software fees.

RESULTS

After 4 withdrawals in each arm, data from a total of 52 patients (telemedicine group: n=26; control group: n=26) were used for our analyses. In the telemedicine group, 77% (20/26) of all patients agreed that telemedicine provided for their health care needs, and 69% (18/26) found telemedicine an acceptable way to receive health care services. In addition, no significant difference was found in the change of patient utility between groups after 3 months (mean 0.02, SD 0.06 vs mean 0.07, SD 0.17; P=.35). Treatment duration was significantly shorter in the intervention group (mean 8.23, SD 4.45 minutes vs mean 10.92, SD 5.58 minutes; P=.02). The use of telemedicine saved 25% (€2.14 [US $2.35]/€8.67 [US $9.53]) in personnel costs and increased the number of treatable patients by 172 annually, assuming 2 hours of video consultations per week. Sensitivity analysis for scaling up video consultations to 10% of the hospital's outpatient cases resulted in personnel cost savings of €73,056 (US $ 80,275.39) for a senior physician. A total of 23 video consultations per month were required to recoup the software fees of telemedicine through reduced personnel costs (break-even point ranging from 12-38 in the sensitivity analysis).

CONCLUSIONS

Our study supports stakeholders' decision-making on the long-term implementation of digital health by demonstrating that video consultations in the follow-up care of patients in orthopedic and trauma surgery result in cost savings and productivity gains for clinics with no negative impact on patient utility.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00023445; https://drks.de/search/en/trial/DRKS00023445.

Economic Evaluations of Digital Health Interventions for Children and Adolescents: Systematic Review

BACKGROUND

Digital health interventions (DHIs) are defined as digital technologies such as digital health applications and information and communications technology systems (including SMS text messages) implemented to meet health objectives. DHIs implemented using various technologies, ranging from electronic medical records to videoconferencing systems and mobile apps, have experienced substantial growth and uptake in recent years. Although the clinical effectiveness of DHIs for children and adolescents has been relatively well studied, much less is known about the cost-effectiveness of these interventions.

OBJECTIVE

This study aimed to systematically review economic evaluations of DHIs for pediatric and adolescent populations. This study also reviewed methodological issues specific to economic evaluations of DHIs to inform future research priorities.

METHODS

We conducted a database search in PubMed from 2011 to 2021 using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist. In total, 2 authors independently screened the titles and abstracts of the search results to identify studies eligible for full-text review. We generated a data abstraction procedure based on recommendations from the Panel on Cost-Effectiveness in Health and Medicine. The types of economic evaluations included in this review were cost-effectiveness analyses (costs per clinical effect), cost-benefit analyses (costs and effects expressed in monetary terms as net benefit), and cost-utility analyses (cost per quality-adjusted life year or disability-adjusted life year). Narrative analysis was used to synthesize the quantitative data because of heterogeneity across the studies. We extracted methodological issues related to study design, analysis framework, cost and outcome measurement, and methodological assumptions regarding the health economic evaluation.

RESULTS

We included 22 articles assessing the cost-effectiveness of DHI interventions for children and adolescents. Most articles (14/22, 64%) evaluated interventions delivered through web-based portals or SMS text messaging, most frequently within the health care specialties of mental health and maternal, newborn, and child health. In 82% (18/22) of the studies, DHIs were found to be cost-effective or cost saving compared with the nondigital standard of care. The key drivers of cost-effectiveness included population coverage, cost components, intervention effect size and scale-up, and study perspective. The most frequently identified methodological challenges were related to study design (17/22, 77%), costing (11/22, 50%), and economic modeling (9/22, 41%).

CONCLUSIONS

This is the first systematic review of economic evaluations of DHIs targeting pediatric and adolescent populations. We found that most DHIs (18/22, 82%) for children and adolescents were cost-effective or cost saving compared with the nondigital standard of care. In addition, this review identified key methodological challenges directly related to the conduct of economic evaluations of DHIs and highlighted areas where further methodological research is required to address these challenges. These included the need for measurement of user involvement and indirect effects of DHIs and the development of children-specific, generic quality-of-life outcomes.

Reaching adults who smoke cigarettes in rural Appalachia: Rationale, design & analysis plan for a mixed-methods study disseminating pharmacy-delivered cessation treatment

INTRODUCTION

Unlike other U.S. geographical regions, cigarette smoking prevalence remains stagnant in rural Appalachia. One avenue for reaching rural residents with evidence-based smoking cessation treatments could be utilizing community pharmacists. This paper describes the design, rationale, and analysis plan for a mixed-method study that will determine combinations of cessation treatment components that can be integrated within community pharmacies in rural Appalachia. The aim is to quantify the individual and synergistic effects of five highly disseminable and sustainable cessation components in a factorial experiment.

METHODS

This sequential, mixed-method research design, based on the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework, will use a randomized controlled trial with a 25 fully crossed factorial design (32 treatment combinations) to test, alone and in combination, the most effective evidence-based cessation components: (1) QuitAid (yes vs. no) (2) tobacco quit line (yes vs. no) (3) SmokefreeTXT (yes vs. no) (4) combination NRT lozenge + NRT patch (vs. NRT patch alone), and (5) eight weeks of NRT (vs. standard four weeks).

RESULTS

Logistic regression will model abstinence at six-months, including indicators for the five treatment factors and all two-way interactions between the treatment factors. Demographic and smoking history variables will be considered to assess potential effect modification. Poisson regression will model quit attempts and percent of adherence to treatment components as secondary outcomes.

CONCLUSION

This study will provide foundational evidence on how community pharmacies in medically underserved, rural regions can be leveraged to increase utilization of existing evidence-based tobacco cessation resources for treating tobacco dependence.

CLINICAL TRIALS

NCT05660525.

Digital tool to identify and monitor regorafenib-associated hand-foot skin reactions: A proof-of-concept study protocol

BACKGROUND

The FACET study is a prospective, open-label, low risk interventional clinical trial aiming at exploring the fitness-for-purpose and usability of an electronic device suite for the detection of hand-foot skin reaction symptoms in patients with metastatic colorectal cancer treated with regorafenib.

METHODS

38 patients with metastatic colorectal cancer are being selected in 6 centers in France, and will be followed for 2 regorafenib treatment cycles, or for approximately 56 days. The electronic device suite includes connected insoles and a mobile device equipped with a camera and a companion application with electronic patient-reported outcomes questionnaires and educational material. The FACET study is intended to provide information useful for the improvement of the electronic device suite and its usability before the testing of its robustness in a larger follow-up study. This paper describes the protocol of the FACET study and discusses the limitations to consider for the implementation of digital devices in real-life practice.

An Evaluation of e-Health Service Performance through the Integration of 5G IoT, Fog, and Cloud Computing

In recent years, Internet of Things (IoT) advancements have led to the development of vastly improved remote healthcare services. Scalability, high bandwidth, low latency, and low power consumption are all essential features of the applications that make these services possible. An upcoming healthcare system and wireless sensor network that can fulfil these needs is based on fifth-generation network slicing. For better resource management, organizations can implement network slicing, which partitions the physical network into distinct logical slices according to quality of service (QoS) needs. Based on the findings of this research, an IoT-fog-cloud architecture is proposed for use in e-Health services. The framework is made up of three different but interconnected systems: a cloud radio access network, a fog computing system, and a cloud computing system. A queuing network serves as a model for the proposed system. The model's constituent parts are then subjected to analysis. To assess the system's performance, we run a numerical example simulation using Java modelling tools and then analyze the results to identify the key performance parameters. The analytical formulas that were derived ensure the precision of the results. Finally, the results show that the proposed model improves eHealth services' quality of service in an efficient way by selecting the right slice compared to the traditional systems.

Costing analysis of an information & communications technology-enabled primary healthcare facility in India

BACKGROUND & OBJECTIVES

Information and communications technology (ICT) has often been endorsed as an effective tool to improve primary healthcare. However, evidence on the cost of ICT-enabled primary health centre (PHC) is lacking. The present study aimed at estimating the costs for customization and implementation of an integrated health information system for primary healthcare at a public sector urban primary healthcare facility in Chandigarh.

METHODS

We undertook economic costing of an ICT-enabled PHC based on health system perspective and bottom-up costing. All the resources used for the provision of ICT-enabled PHC, capital and recurrent, were identified, measured and valued. The capital items were annualized over their estimated life using a discount rate of 3 per cent. A sensitivity analysis was undertaken to assess the effect of parameter uncertainties. Finally, we assessed the cost of scaling up ICT-enabled PHC at the state level.

RESULTS

The estimated overall annual cost of delivering health services through PHC in the public sector was ₹ 7.88 million. The additional economic cost of ICT was ₹ 1.39 million i.e. 17.7 per cent over and above a non-ICT PHC cost. In a PHC with ICT, the cost per capita increased by ₹ 56. On scaling up to the state level (with 400 PHCs), the economic cost of ICT was estimated to be ₹ 0.47 million per year per PHC, which equates to approximately six per cent expenditure over and above the economic cost of a regular PHC.

INTERPRETATION & CONCLUSIONS

Implementing a model of information technology-PHC in a state of India would require an augmentation of cost by about six per cent, which seems fiscally sustainable. However, contextual factors related to the availability of infrastructure, human resources and medical supplies for delivering quality PHC services will also need to be considered.

Economic and Performance Evaluation of E-Health before and after the Pandemic Era: A Literature Review and Future Perspectives

E-Health represents one of the pillars of the modern healthcare system and a strategy involving the use of digital and telemedicine tools to provide assistance to an increasing number of patients, reducing, at the same time, healthcare costs. Measuring and understanding the economic value and performance of e-Health tools is, therefore, essential to understanding the outcome and best uses of such technologies. The aim of this paper is to determine the most frequently used methods for measuring the economic value and the performance of services in the framework of e-Health, considering different pathologies. An in-depth analysis of 20 recent articles, rigorously selected from more than 5000 contributions, underlines a great interest from the clinical community in economic and performance-related topics. Several diseases are the object of detailed clinical trials and protocols, leading to various economic outcomes, especially in the COVID-19 post-pandemic era. Many e-Health tools are mentioned in the studies, especially those that appear more frequently in people's lives outside of the clinical setting, such as apps and web portals, which allow for clinicians to keep in contact with their patients. While such e-Health tools and programs are increasingly studied from practical perspectives, such as in the case of Virtual Hospital frameworks, there is a lack of consensus regarding the recommended models to map and report their economic outcomes and performance. More investigations and guidelines by scientific societies are advised to understand the potential and path of such an evolving and promising phenomenon.

Analytical Frameworks and Outcome Measures in Economic Evaluations of Digital Health Interventions: A Methodological Systematic Review

BACKGROUND

Digital health interventions (DHIs) can improve the provision of health care services. To fully account for their effects in economic evaluations, traditional methods based on measuring health-related quality of life may not be appropriate, as nonhealth and process outcomes are likely to be relevant too.

PURPOSE

This systematic review identifies, assesses, and synthesizes the arguments on the analytical frameworks and outcome measures used in the economic evaluations of DHIs. The results informed recommendations for future economic evaluations.

DATA SOURCES

We ran searches on multiple databases, complemented by gray literature and backward and forward citation searches.

STUDY SELECTION

We included records containing theoretical and empirical arguments associated with the use of analytical frameworks and outcome measures for economic evaluations of DHIs. Following title/abstract and full-text screening, our final analysis included 15 studies.

DATA EXTRACTION

The arguments we extracted related to analytical frameworks (14 studies), generic outcome measures (5 studies), techniques used to elicit utility values (3 studies), and disease-specific outcome measures and instruments to collect health states data (both from 2 studies).

DATA SYNTHESIS

Rather than assessing the quality of the studies, we critically assessed and synthesized the extracted arguments. Building on this synthesis, we developed a 3-stage set of recommendations in which we encourage the use of impact matrices and analyses of equity impacts to integrate traditional economic evaluation methods.

LIMITATIONS

Our review and recommendations explored but not fully covered other potentially important aspects of economic evaluations that were outside our scope.

CONCLUSIONS

This is the first systematic review that summarizes the arguments on how the effects of DHIs could be measured in economic evaluations. Our recommendations will help design future economic evaluations.

HIGHLIGHTS

Using traditional outcome measures based on health-related quality of life (such as the quality-adjusted life-year) may not be appropriate in economic evaluations of digital health interventions, which are likely to trigger nonhealth and process outcomes.This is the first systematic review to investigate how the effects of digital health interventions could be measured in economic evaluations.We extracted and synthesized different arguments from the literature, outlining advantages and disadvantages associated with different methods used to measure the effects of digital health interventions.We propose a methodological set of recommendations in which 1) we suggest that researchers consider the use of impact matrices and cost-consequence analysis, 2) we discuss the suitability of analytical frameworks and outcome measures available in economic evaluations, and 3) we highlight the need for analyses of equity impacts.

Economic and Environmental Impact of Digital Health App Video Consultations in Follow-up Care for Patients in Orthopedic and Trauma Surgery in Germany: Randomized Controlled Trial

BACKGROUND

Following the Riyadh Declaration, digital health technologies were prioritized in many countries to address the challenges of the COVID-19 pandemic. Digital health apps for telemedicine and video consultations help reduce potential disease spread in routine health care, including follow-up care in orthopedic and trauma surgery. In addition to the satisfaction, efficiency, and safety of telemedicine, its economic and environmental effects are highly relevant to decision makers, particularly for the goal of reaching carbon neutrality of health care systems.

OBJECTIVE

This study aims to provide the first comprehensive health economic and environmental analysis of video consultations in follow-up care after knee and shoulder interventions in an orthopedic and trauma surgery department of a German university hospital. The analysis is conducted from a societal perspective. We analyze both economic and environmental impacts of video consultations, taking into account the goal of carbon neutrality for the German health care system by 2030.

METHODS

We conducted a prospective randomized controlled trial comparing follow-up care with digital health app video consultations (intervention group) to conventional face-to-face consultations in the clinic (control group). Economic impact included the analysis of travel and time costs and production losses. Examination of the environmental impact comprised the emissions of greenhouse gases, carbon monoxide, volatile hydrocarbons, nitrogen oxides, and particulates, and the calculation of environmental costs. Sensitivity analysis included calculations with a higher cost per ton of carbon dioxide equivalent, which gives equal weight to the welfare of present and future generations.

RESULTS

Data from 52 patients indicated that, from the patients' point of view, telemedicine helped reduce travel costs, time costs, and production losses, resulting in mean cost savings of €76.52 per video consultation. In addition, emissions of 11.248 kg of greenhouse gases, 0.070 kg of carbon monoxide, 0.011 kg of volatile hydrocarbons, 0.028 kg of nitrogen oxides, and 0.0004 kg of particulates could be saved per patient through avoided travel. This resulted in savings of environmental costs between €3.73 and €9.53 per patient.

CONCLUSIONS

We presented the first comprehensive analysis of economic and environmental effects of telemedicine in the follow-up care of patients in orthopedic and trauma surgery in Germany. Video consultations were found to reduce the environmental footprint of follow-up care; saved travel costs, travel time, and time costs for patients; and helped to lower production losses. Our findings can support the decision-making on the use of digital health during and beyond the COVID-19 pandemic, providing decision makers with data for both economic and environmental effects. Thanks to the pragmatic design of our study, our findings can be applied to a wide range of clinical contexts and potential digital health applications that substitute outpatient hospital visits with video consultations.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00023445; https://tinyurl.com/4pcvhz4n.

Mobile for Mothers mHealth Intervention to Augment Maternal Health Awareness and Behavior of Pregnant Women in Tribal Societies: Randomized Quasi-Controlled Study

Background

Despite several initiatives taken by government bodies, disparities in maternal health have been noticeable across India’s socioeconomic gradient due to poor health awareness.

Objective

The aim of this study was to implement an easy-to-use mobile health (mHealth) app—Mobile for Mothers (MfM)—as a supporting tool to improve (1) maternal health awareness and (2) maternal health–related behavioral changes among tribal and rural communities in India.

Methods

Pregnant women, aged 18 to 45 years, were selected from two rural villages of Jharkhand, India: (1) the intervention group received government-mandated maternal care through an mHealth app and (2) the control group received the same government-mandated care via traditional means (ie, verbally). A total of 800 accredited social health activists (ASHAs) were involved, of which 400 were allocated to the intervention group. ASHAs used the MfM app to engage with pregnant women during each home visit in the intervention group. The mHealth intervention commenced soon after the baseline survey was completed in February 2014. The end-line data were collected between November 2015 and January 2016. We calculated descriptive statistics related to demographics and the percentage changes for each variable between baseline and end line per group. The baseline preintervention groups were compared to the end-line postintervention groups using Pearson chi-square analyses. Mantel-Haenszel tests for conditional independence were conducted to determine if the pre- to postintervention differences in the intervention group were significantly different from those in the control group.

Results

Awareness regarding the five cleans (5Cs) in the intervention group increased (P<.001) from 143 (baseline) to 555 (end line) out of 740 participants. Awareness about tetanus vaccine injections and the fact that pregnant women should receive two shots of tetanus vaccine in the intervention group significantly increased (P<.001) from 73 out of 740 participants (baseline) to 372 out of 555 participants (end line). In the intervention group, awareness regarding the fact that problems like painful or burning urination and itchy genitals during pregnancy are indicative of a reproductive tract infection increased (P<.001) from 15 (baseline) to 608 (end line) out of 740 participants. Similarly, knowledge about HIV testing increased (P<.001) from 39 (baseline) to 572 (end line) out of 740 participants. We also noted that the number of pregnant women in the intervention group who consumed the prescribed dosage of iron tablets increased (P<.001) from 193 (baseline) out of 288 participants to 612 (end line) out of 663 participants.

Conclusions

mHealth interventions can augment awareness of, and persistence in, recommended maternal health behaviors among tribal communities in Jharkhand, India. In addition, mHealth could act as an educational tool to help tribal societies break away from their traditional beliefs about maternal health and take up modern health care recommendations.

Trial Registration

OSF Registries 9U8D5; https://doi.org/10.17605/OSF.IO/9U8D5

Consumers’ Willingness to Pay for eHealth and Its Influencing Factors: Systematic Review and Meta-analysis

Background

Despite the great potential of eHealth, substantial costs are involved in its implementation, and it is essential to know whether these costs can be justified by its benefits. Such needs have led to an increased interest in measuring the benefits of eHealth, especially using the willingness to pay (WTP) metric as an accurate proxy for consumers’ perceived benefits of eHealth. This offered us an opportunity to systematically review and synthesize evidence from the literature to better understand WTP for eHealth and its influencing factors.

Objective

This study aimed to provide a systematic review of WTP for eHealth and its influencing factors.

Methods

This study was performed and reported as per the Cochrane Collaboration and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, CINAHL Plus, Cochrane Library, EconLit, and PsycINFO databases were searched from their inception to April 19, 2022. We conducted random-effects meta-analyses to calculate WTP values for eHealth (at 2021 US dollar rates) and meta-regression analyses to examine the factors affecting WTP.

Results

A total of 30 articles representing 35 studies were included in the review. We found that WTP for eHealth varied across studies; when expressed as a 1-time payment, it ranged from US $0.88 to US $191.84, and when expressed as a monthly payment, it ranged from US $5.25 to US $45.64. Meta-regression analyses showed that WTP for eHealth was negatively associated with the percentages of women (β=−.76; P<.001) and positively associated with the percentages of college-educated respondents (β=.63; P<.001) and a country’s gross domestic product per capita (multiples of US $1000; β=.03; P<.001). Compared with eHealth provided through websites, people reported a lower WTP for eHealth provided through asynchronous communication (β=−1.43; P<.001) and a higher WTP for eHealth provided through medical devices (β=.66; P<.001), health apps (β=.25; P=.01), and synchronous communication (β=.58; P<.001). As for the methods used to measure WTP, single-bounded dichotomous choice (β=2.13; P<.001), double-bounded dichotomous choice (β=2.20; P<.001), and payment scale (β=1.11; P<.001) were shown to obtain higher WTP values than the open-ended format. Compared with ex ante evaluations, ex post evaluations were shown to obtain lower WTP values (β=−.37; P<.001).

Conclusions

WTP for eHealth varied significantly depending on the study population, modality used to provide eHealth, and methods used to measure it. WTP for eHealth was lower among certain population segments, suggesting that these segments may be at a disadvantage in terms of accessing and benefiting from eHealth. We also identified the modalities of eHealth that were highly valued by consumers and offered suggestions for the design of eHealth interventions. In addition, we found that different methods of measuring WTP led to significantly different WTP estimates, highlighting the need to undertake further methodological explorations of approaches to elicit WTP values.

Compassionate Technology: A Systematic Scoping Review of Compassion as Foundation for Blended and Digital Mental Health Interventions (Preprint)

BACKGROUND

An essential value in mental health care is compassion: awareness of suffering, tolerating difficult feelings in the face of suffering, and acting or being motivated to alleviate suffering. Currently, technologies for mental health care are on the rise and could offer several advantages, such as more options for self-management by clients and more accessible and economically viable care. However, digital mental health interventions (DMHIs) have not been widely implemented in daily practice. Developing and evaluating DMHIs around important mental health care values, such as compassion, could be key for a better integration of technology in the mental health care context.

OBJECTIVE

This systematic scoping review explored the literature for previous instances where technology for mental health care has been linked to compassion or empathy to investigate how DMHIs can support compassion in mental health care.

METHODS

Searches were conducted in the PsycINFO, PubMed, Scopus, and Web of Science databases, and screening by 2 reviewers resulted in 33 included articles. From these articles, we extracted the following data: technology types, goals, target groups, and roles of the technologies in the intervention; study designs; outcome measures; and the extent to which the technologies met a 5-step proposed definition of compassion.

RESULTS

We found 3 main ways in which technology can contribute to compassion in mental health care: by showing compassion to people, by enhancing self-compassion in people, or by facilitating compassion between people. However, none of the included technologies met all 5 elements of compassion nor were they evaluated in terms of compassion.

CONCLUSIONS

We discuss the potential of compassionate technology, its challenges, and the need to evaluate technology for mental health care on compassion. Our findings could contribute to the development of compassionate technology, in which elements of compassion are explicitly embedded in its design, use, and evaluation.

Cost-Utility of the eHealth Application ‘Oncokompas’, Supporting Incurably Ill Cancer Patients to Self-Manage Their Cancer-Related Symptoms: Results of a Randomized Controlled Trial

Evidence on the cost-effectiveness of eHealth in palliative care is scarce. Oncokompas, a fully automated behavioral intervention technology, aims to support self-management in cancer patients. This study aimed to assess the cost-utility of the eHealth application Oncokompas among incurably ill cancer patients, compared to care as usual. In this randomized controlled trial, patients were randomized into the intervention group (access to Oncokompas) or the waiting-list control group (access after three months). Healthcare costs, productivity losses, and health status were measured at baseline and three months. Intervention costs were also taken into account. Non-parametric bootstrapping with 5000 replications was used to obtain 95% confidence intervals around the incremental costs and quality-adjusted life years (QALYs). A probabilistic approach was used because of the skewness of cost data. Altogether, 138 patients completed the baseline questionnaire and were randomly assigned to the intervention group (69) or the control group (69). In the base case analysis, mean total costs and mean total effects were non-significantly lower in the intervention group (−€806 and −0.01 QALYs). The probability that the intervention was more effective and less costly was 4%, whereas the probability of being less effective and less costly was 74%. Among patients with incurable cancer, Oncokompas does not impact incremental costs and seems slightly less effective in terms of QALYs, compared to care as usual. Future research on the costs of eHealth in palliative cancer care is warranted to assess the generalizability of the findings of this study.

The cost-effectiveness of digital health interventions: A systematic review of the literature

Background

Digital health interventions have significant potential to improve safety, efficacy, and quality of care, reducing waste in healthcare costs. Despite these premises, the evidence regarding cost and effectiveness of digital tools in health is scarce and limited.

Objectives

The aim of this systematic review is to summarize the evidence on the cost-effectiveness of digital health interventions and to assess whether the studies meet the established quality criteria.

Methods

We queried PubMed, Scopus and Web of Science databases for articles in English published from January 1, 2016 to December 31, 2020 that performed economic evaluations of digital health technologies. The methodological rigorousness of studies was assessed with the Consolidated Health Economic Evaluation Reporting Standards (CHEERS). The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2009 checklist.

Results

Search identified 1,476 results, 552 of which were selected for abstract and 35 were included in this review. The studies were heterogeneous by country (mostly conducted in upper and upper-middle income countries), type of eHealth intervention, method of implementation, and reporting perspectives. The qualitative analysis identified the economic and effectiveness evaluation of six different types of interventions: (1) seventeen studies on new video-monitoring service systems; (2) five studies on text messaging interventions; (3) five studies on web platforms and digital health portals; (4) two studies on telephone support; (5) three studies on new mobile phone-based systems and applications; and (6) three studies on digital technologies and innovations.

Conclusion

Findings on cost-effectiveness of digital interventions showed a growing body of evidence and suggested a generally favorable effect in terms of costs and health outcomes. However, due to the heterogeneity across study methods, the comparison between interventions still remains difficult. Further research based on a standardized approach is needed in order to methodically analyze incremental cost-effectiveness ratios, costs, and health benefits.

Usability Study of the iACTwithPain Platform: An Online Acceptance and Commitment Therapy and Compassion-Based Intervention for Chronic Pain

Background

This pilot study aims to test the usability of the iACTwithPain platform, an online ACT-based intervention for people with chronic pain, to obtain information on which intervention and usability aspects need improvement and on expected retention rates.

Methods

Seventy-three Portuguese women with chronic pain were invited to complete the first three sessions of the iACTwithPain intervention assess their quality, usefulness and the platform’s usability. Twenty-one accepted the invitation. Additionally, eight healthcare professionals working with chronic medical conditions assessed the platform and the intervention from a practitioner’s point of view.

Results

This study presented a considerable attrition rate (71.43%) among chronic pain participants, with six completers. There were no significant differences in demographic or clinical variables between dropouts and completers except for completed education (participants who dropped out presented less education than completers). Reasons for dropout were related to difficult personal events occurring during the time of the intervention, lack of time, or having forgotten. There seemed to be an overall satisfaction with both the intervention, its contents and form of presentation of information, and the platform, concerning its design, appearance, and usability. Real image videos were preferred over animations or audio by chronic pain participants. Healthcare professionals emphasized the appealing and dynamic aspects of the animation format.

Conclusion

This study informs the ongoing improvement of the iACTwithPain platform and provides valuable information on aspects researchers should consider while developing online psychological interventions for chronic pain. Further implications are discussed.

Health economic evaluation of digital nursing technologies: a review of methodological recommendations

BACKGROUND

Health economic evaluation of digital nursing technologies (DNT) is important to provide information that helps avoid undesirable developments and implementations as well as increase the chances of success of developed applications. At the same time, studies and evidence on cost-effectiveness are still very rare in this field. Review studies in related technology areas such as telemedicine frequently criticise the quality and comparability of health economic evaluations conducted in this field. Based on a content analysis of methodological literature on the economic evaluation of innovative (digital) technologies in health and nursing, this article aims to identify specific challenges in this research area and offers recommendations on how to address these challenges to promote more sound health economic evaluations in the future.

METHODS

A rapid review was conducted, consisting of a systematic search in the Pubmed database as well as Google Scholar. In addition, the literature lists of the analysed texts were scoured for additional texts to be included. Methodological literature, single studies, and reviews were included. A total of 536 studies were screened, of which 29 were included in the full text analysis.

RESULTS

Based on the systematic content analysis of the studies under consideration, 10 specific methodological challenges are identified, and the methodological recommendations were examined for consideration. A particular focus was given to whether specific methodological approaches might be needed in the context of evaluating the efficiency of DNT.

CONCLUSION

Many of the challenges identified for the health economic evaluations of digital nursing technologies are comparable to those of other complex health care interventions. The recommendations discussed can help to alleviate those challenges. Future research should focus on alternative approaches to assessing causality in different phases of technology development while maintaining high evidence standards. High-evidence economic assessment of technologies in nursing care should be carried out in routine use, especially if they are intended to be reimbursed by the social insurance.

Searching for Sustainability in Health Systems: Toward a Multidisciplinary Evaluation of Mobile Health Innovations

Mobile health (mHealth) innovations are considered by governments as game changers toward more sustainable health systems. The existing literature focuses on the clinical aspects of mHealth but lacks an integrated framework on its sustainability. The foundational idea for this paper is to include disciplinary complementarities into a multi-dimensional vision to evaluate the non-clinical aspects of mHealth innovations. We performed a targeted literature review to find how the sustainability of mHealth innovations was appraised in each discipline. We found that each discipline considers a different outcome of interest and adopts different time horizons and perspectives for the evaluation. This article reflects on how the sustainability of mHealth innovation can be assessed at both the level of the device itself as well as the level of the health system. We identify some of the challenges ahead of researchers working on mobile health innovations in contributing to shaping a more sustainable health system.

Study protocol for a modified antenatal care program for pregnant women with a low risk for adverse outcomes-a stepped wedge cluster non-inferiority randomized trial

BACKGROUND

It is crucial to provide care based on individual needs. Swedish health care is obliged to give care on equal conditions for the entire population. The person with the greatest need should be given the most care, and the health care system should strive to be cost-efficient. Medical and technical advances have been significant during the last decades and the recent Covid-19 pandemic has caused a shift in health care, from in-person visits to virtual visits. The majority of pregnant women with a low risk assessment have an uncomplicated antenatal course without adverse events. These women probably receive excessive and unnecessary antenatal care. This study will investigate if an antenatal care program for healthy pregnant women with a low risk for adverse outcomes could be safely monitored with fewer in-person visits to a midwife, and with some of them replaced by virtual visits.

METHODS

This is a non-inferiority trial where a stepped wedge cluster randomized controlled design will be used. Data collection includes register data and questionnaires that concern antenatal, obstetric and neonatal outcomes, patient- and caregiver-reported experiences, healthcare-economy, and implementation aspects. The modified antenatal care (MAC) study is performed in parts of the southeast of Sweden, which has approximately 8200 childbirths annually. At the start of the study, all antenatal care centers included in the study will use the same standard antenatal care (SAC) program. In the MAC program the in-person visits to a midwife will be reduced to four instead of eight, with two additional virtual meetings compared with the SAC program.

DISCUSSION

This presented study protocol is informed by research knowledge. The protocol is expected to provide a good structure for future studies on changed antenatal care programs that introduce virtual visits for healthy pregnant women with a low risk for adverse outcomes, without risking quality, safety, and increased costs.

TRIAL REGISTRATION

The study is registered the 21th of April 2021 in the ISRCTN registry with trial ID: ISRCTN14422582 , retrospectively registered.

Economic Evaluation of Digital Health Interventions: Methodological Issues and Recommendations for Practice

Health care interventions are increasingly being delivered through digital technologies, offering major opportunities for delivering more health gains from scarce health care resources. Digital health interventions (DHIs) raise distinct challenges for economic evaluations compared with drugs and medical devices, not least due to their interacting, evolving features. The implications of the distinctive nature of DHIs for the methodological choices underpinning their economic evaluation is not well understood. This paper provides an in-depth discussion of distinct features of DHIs and how they might impact the design, measurement, analysis and reporting of cost-effectiveness analysis conducted alongside both randomised and non-randomised studies. These include aspects related to choice of comparator, costs and benefits assessment, study perspective and type of economic analysis. We argue that typical methodological standpoints, such as taking a health service perspective, focusing on health-related benefits and adopting cost-utility analyses, as typically adopted in the economic evaluation of non-digital technologies (pharmaceutical drugs and medical devices), are unlikely to be appropriate for DHIs. We illustrate how these methodological aspects can be appropriately addressed in an evaluation of a digitally supported, remote rehabilitation programme for patients with Long Covid in England. We highlight several methodological considerations for improving practice and areas where further methodological work is required.

Online-Delivered Over Staff-Delivered Parenting Intervention for Young Children With Disruptive Behavior Problems: Cost-Minimization Analysis

BACKGROUND

High-prevalence childhood mental health problems like early-onset disruptive behavior problems (DBPs) pose a significant public health challenge and necessitate interventions with adequate population reach. The treatment approach of choice for childhood DBPs, namely evidence-based parenting intervention, has not been sufficiently disseminated when relying solely on staff-delivered services. Online-delivered parenting intervention is a promising strategy, but the cost minimization of this delivery model for reducing child DBPs is unknown compared with the more traditional staff-delivered modality.

OBJECTIVE

This study aimed to examine the cost-minimization of an online parenting intervention for childhood disruptive behavior problems compared with the staff-delivered version of the same content. This objective, pursued in the context of a randomized trial, made use of cost data collected from parents and service providers.

METHODS

A cost-minimization analysis (CMA) was conducted comparing the online and staff-delivered parenting interventions. Families (N=334) with children 3-7 years old, who exhibited clinically elevated disruptive behavior problems, were randomly assigned to the two parenting interventions. Participants, delivery staff, and administrators provided data for the CMA concerning family participation time and expenses, program delivery time (direct and nondirect), and nonpersonnel resources (eg, space, materials, and access fee). The CMA was conducted using both intent-to-treat and per-protocol analytic approaches.

RESULTS

For the intent-to-treat analyses, the online parenting intervention reflected significantly lower program costs (t₁₆₈=23.2; P<.001), family costs (t₁₈₅=9.2; P<.001), and total costs (t₁₇₁=19.1; P<.001) compared to the staff-delivered intervention. The mean incremental cost difference between the interventions was $1164 total costs per case. The same pattern of significant differences was confirmed in the per-protocol analysis based on the families who completed their respective intervention, with a mean incremental cost difference of $1483 per case. All costs were valued or adjusted in 2017 US dollars.

CONCLUSIONS

The online-delivered parenting intervention in this randomized study produced substantial cost minimization compared with the staff-delivered intervention providing the same content. Cost minimization was driven primarily by personnel time and, to a lesser extent, by facilities costs and family travel time. The CMA was accomplished with three critical conditions in place: (1) the two intervention delivery modalities (ie, online and staff) held intervention content constant; (2) families were randomized to the two parenting interventions; and (3) the online-delivered intervention was previously confirmed to be non-inferior to the staff-delivered intervention in significantly reducing the primary outcome, child disruptive behavior problems. Given those conditions, cost minimization for the online parenting intervention was unequivocal.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02121431; https://clinicaltrials.gov/ct2/show/NCT02121431.

Cost data in implementation science: categories and approaches to costing

A lack of cost information has been cited as a barrier to implementation and a limitation of implementation research. This paper explains how implementation researchers might optimize their measurement and inclusion of costs, building on traditional economic evaluations comparing costs and effectiveness of health interventions. The objective of all economic evaluation is to inform decision-making for resource allocation and to measure costs that reflect opportunity costs—the value of resource inputs in their next best alternative use, which generally vary by decision-maker perspective(s) and time horizon(s). Analyses that examine different perspectives or time horizons must consider cost estimation accuracy, because over longer time horizons, all costs are variable; however, with shorter time horizons and narrower perspectives, one must differentiate the fixed and variable costs, with fixed costs generally excluded from the evaluation. This paper defines relevant costs, identifies sources of cost data, and discusses cost relevance to potential decision-makers contemplating or implementing evidence-based interventions. Costs may come from the healthcare sector, informal healthcare sector, patient, participant or caregiver, and other sectors such as housing, criminal justice, social services, and education. Finally, we define and consider the relevance of costs by phase of implementation and time horizon, including pre-implementation and planning, implementation, intervention, downstream, and adaptation, and through replication, sustainment, de-implementation, or spread.

Development and delivery cost of digital health technologies for mental health: Application to the Narrative Experiences Online Intervention

BACKGROUND

The increasing development and use of digital health interventions requires good quality costing information to inform development and commissioning choices about resource allocation decisions. The Narrative Experiences Online (NEON) Intervention is a web-application that delivers recorded mental health recovery narratives to its users. Two randomized controlled trials are testing the NEON Intervention in people with experience of psychosis (NEON) and people experiencing non-psychosis mental health problems (NEON-O).

AIM

This study describes and estimates the cost components and total cost of developing and delivering the NEON Intervention.

MATERIALS AND METHODS

Total costs for the NEON Trial (739 participants) and NEON-O Trial (1,024 participants) were estimated by: identifying resource use categories involved in intervention development and delivery; accurate measurement or estimation of resource use; and a valuation of resource use to generate overall costs, using relevant unit costs. Resource use categories were identified through consultation with literature, costing reporting standards and iterative consultation with health researchers involved in NEON Intervention development and delivery. Sensitivity analysis was used to test assumptions made.

RESULTS

The total cost of developing the NEON Intervention was £182,851. The largest cost components were software development (27%); Lived Experience Advisory Panel workshops (23%); coding the narratives (9%); and researchers' time to source narratives (9%). The total cost of NEON Intervention delivery during the NEON Trial was £118,663 (£349 per NEON Intervention user). In the NEON-O Trial, the total delivery cost of the NEON Intervention was £123,444 (£241 per NEON Intervention user). The largest cost components include updating the narrative collection (50%); advertising (19%); administration (14%); and software maintenance (11%). Uncertainty in the cost of administration had the largest effect on delivery cost estimates.

CONCLUSION

Our work shows that developing and delivering a digital health intervention requires expertise and time commitment from a range of personnel. Teams developing digital narrative interventions need to allocate substantial resources to curating narrative collections.

IMPLICATIONS FOR PRACTICE

This study identifies the development and delivery resource use categories of a digital health intervention to promote the consistent reporting of costs and informs future decision-making about the costs of delivering the NEON Intervention at scale.

TRIAL REGISTRATION

NEON Trial: ISRCTN11152837, registered 13 August 2018, http://www.isrctn.com/ISRCTN11152837. NEON-O Trial: ISRCTN63197153, registered 9 January 2020, http://www.isrctn.com/ISRCTN63197153.

Digital health in oncology in Africa: A scoping review and cross-sectional survey

BACKGROUND

Low- and middle-income countries, especially in Africa, face a growing cancer burden. Adoption of digital health solutions has the potential to improve cancer care delivery and research in these countries. However, the extent of implementation and the impact of digital health interventions across the cancer continuum in Africa have not been studied.

AIMS

To describe the current landscape of digital health interventions in oncology in Africa.

METHODS

We conducted a scoping literature review and supplemented this with a survey. Following the PRISMA for Scoping Reviews guidelines, we searched literature in PubMed and Embase for keywords and synonyms for cancer, digital health, and African countries, and abstracted data using a structured form. For the survey, participants were delegates of the 2019 conference of the African Organization for Research and Training in Cancer.

RESULTS

The literature review identified 57 articles describing 40 digital health interventions or solutions from 17 African countries, while the survey included 111 respondents from 18 African countries, and these reported 25 different digital health systems. Six articles (10.5%) reported randomized controlled trials. The other 51 articles (89.5%) were descriptive or quasi-experimental studies. The interventions mostly targeted cancer prevention (28 articles, 49.1%) or diagnosis and treatment (23 articles, 40.4%). Four articles (7.0%) targeted survivorship and end of life, and the rest were cross-cutting. Cervical cancer was the most targeted cancer (25 articles, 43.9%). Regarding WHO classification of digital interventions, most were for providers (35 articles, 61.4%) or clients (13, 22.8%), while the others were for data services or cut across these categories. The interventions were mostly isolated pilots using basic technologies such as SMS and telephone calls for notifying patients of their appointments or results, or for cancer awareness; image capture apps for cervical cancer screening, and tele-conferencing for tele-pathology and mentorship. Generally positive results were reported, but evaluation focused on structure and process measures such as ease of use, infrastructure requirements, and acceptability of intervention; or general benefits e.g. supporting training and mentorship of providers, communication among providers and clients, and improving data collection and management. No studies evaluated individualized clinical outcomes, and there were no interventions in literature for health system managers although the systems identified in the survey had such functionality, e.g. inventory management. The survey also indicated that none of the digital health systems had all the functionalities for a comprehensive EHR, and major barriers for digital health were initial and ongoing costs, resistance from clinical staff, and lack of fit between the EHR and the clinical workflows.

CONCLUSION

Digital health interventions in oncology in Africa are at early maturity stages but promising. Barriers such as funding, fit between digital health tools and clinical workflows, and inertia towards technology, shall need to be addressed to allow for advancement of digital health solutions to support all parts of the cancer continuum. Future research should investigate the impact of digital health solutions on long-term cancer outcomes such as cancer mortality, morbidity and quality of life.

Successes of and Lessons From the First Joint eHealth Program of the Dutch University Hospitals: Evaluation Study

BACKGROUND

A total of 8 Dutch university hospitals are at the forefront of contributing meaningfully to a future-proof health care system. To stimulate nationwide collaboration and knowledge-sharing on the topic of evidence-based eHealth, the Dutch university hospitals joined forces from 2016 to 2019 with the first Citrien Fund (CF) program eHealth; 29 eHealth projects with various subjects and themes were selected, supported, and evaluated. To determine the accomplishment of the 10 deliverables for the CF program eHealth and to contribute to the theory and practice of formative evaluation of eHealth in general, a comprehensive evaluation was deemed essential.

OBJECTIVE

The first aim of this study is to evaluate whether the 10 deliverables of the CF program eHealth were accomplished. The second aim is to evaluate the progress of the 29 eHealth projects to determine the barriers to and facilitators of the development of the CF program eHealth projects.

METHODS

To achieve the first aim of this study, an evaluation study was carried out using an adapted version of the Commonwealth Scientific and Industrial Research Organization framework. A mixed methods study, consisting of a 2-part questionnaire and semistructured interviews, was conducted to analyze the second aim of the study.

RESULTS

The 10 deliverables of the CF program eHealth were successfully achieved. The program yielded 22 tangible eHealth solutions, and significant knowledge on the development and use of eHealth solutions. We have learned that the patient is enthusiastic about accessing and downloading their own medical data but the physicians are more cautious. It was not always possible to implement the Dutch set of standards for interoperability, owing to a lack of information technology (IT) capacities. In addition, more attention needed to be paid to patients with low eHealth skills, and education in such cases is important. The eHealth projects' progress aspects such as planning, IT services, and legal played an important role in the success of the 29 projects. The in-depth interviews illustrated that a novel eHealth solution should fulfill a need, that partners already having the knowledge and means to accelerate development should be involved, that clear communication with IT developers and other stakeholders is crucial, and that having a dedicated project leader with sufficient time is of utmost importance for the success of a project.

CONCLUSIONS

The 8 Dutch university hospitals were able to collaborate successfully and stimulate through a bottom-up approach, nationwide eHealth development and knowledge-sharing. In total, 22 tangible eHealth solutions were developed, and significant eHealth knowledge about their development and use was shared. The eHealth projects' progress aspects such as planning, IT services, and legal played an important role in the successful progress of the projects and should therefore be closely monitored when developing novel eHealth solutions.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1016/j.ceh.2020.12.002.

Successes of and Lessons From the First Joint eHealth Program of the Dutch University Hospitals: Evaluation Study

BACKGROUND

A total of 8 Dutch university hospitals are at the forefront of contributing meaningfully to a future-proof health care system. To stimulate nationwide collaboration and knowledge-sharing on the topic of evidence-based eHealth, the Dutch university hospitals joined forces from 2016 to 2019 with the first Citrien Fund (CF) program eHealth; 29 eHealth projects with various subjects and themes were selected, supported, and evaluated. To determine the accomplishment of the 10 deliverables for the CF program eHealth and to contribute to the theory and practice of formative evaluation of eHealth in general, a comprehensive evaluation was deemed essential.

OBJECTIVE

The first aim of this study is to evaluate whether the 10 deliverables of the CF program eHealth were accomplished. The second aim is to evaluate the progress of the 29 eHealth projects to determine the barriers to and facilitators of the development of the CF program eHealth projects.

METHODS

To achieve the first aim of this study, an evaluation study was carried out using an adapted version of the Commonwealth Scientific and Industrial Research Organization framework. A mixed methods study, consisting of a 2-part questionnaire and semistructured interviews, was conducted to analyze the second aim of the study.

RESULTS

The 10 deliverables of the CF program eHealth were successfully achieved. The program yielded 22 tangible eHealth solutions, and significant knowledge on the development and use of eHealth solutions. We have learned that the patient is enthusiastic about accessing and downloading their own medical data but the physicians are more cautious. It was not always possible to implement the Dutch set of standards for interoperability, owing to a lack of information technology (IT) capacities. In addition, more attention needed to be paid to patients with low eHealth skills, and education in such cases is important. The eHealth projects' progress aspects such as planning, IT services, and legal played an important role in the success of the 29 projects. The in-depth interviews illustrated that a novel eHealth solution should fulfill a need, that partners already having the knowledge and means to accelerate development should be involved, that clear communication with IT developers and other stakeholders is crucial, and that having a dedicated project leader with sufficient time is of utmost importance for the success of a project.

CONCLUSIONS

The 8 Dutch university hospitals were able to collaborate successfully and stimulate through a bottom-up approach, nationwide eHealth development and knowledge-sharing. In total, 22 tangible eHealth solutions were developed, and significant eHealth knowledge about their development and use was shared. The eHealth projects' progress aspects such as planning, IT services, and legal played an important role in the successful progress of the projects and should therefore be closely monitored when developing novel eHealth solutions.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1016/j.ceh.2020.12.002.

Economic Evaluation of Digital Health Interventions in Palliative Care: A Systematic Review of the Literature

Introduction: Digital health interventions can facilitate the provision of palliative care. However, the economic evaluation of such interventions has not yet been a standard practice. The present study aimed to identify the existing literature on the particular subject.

Methods: A systematic search was conducted in six literature databases between 2010 and 2021: PubMed, Scopus, DARE, NHS EED, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials. Methodological quality was assessed with the Drummond Checklist.

Results: The search identified 423 publications, 66 of which were removed as duplicates, resulting in 357 records to be screened by title and abstract. Ten studies were subjected to full-text review and 3 were included in the analysis. The interventions of these studies referred to video consultations and eHealth interventions for symptom management. Overall, the digital health interventions incurred lower costs compared with usual care or no intervention and were considered cost saving and cost-effective. The methodological quality of the studies was considered good.

Conclusion: The results of this systematic review indicate that the use of digital health interventions has the potential to be cost-effective in palliative care. However, applicability and generalizability of the evidence is uncertain, mainly due to methodological heterogeneity and scarcity of research.

Responsible Relations: A Systematic Scoping Review of the Therapeutic Alliance in Text-Based Digital Psychotherapy

Introduction: Developing a good therapeutic alliance is considered essential for the responsible delivery of psychotherapy. Text-based digital psychotherapy has become increasingly common, yet much remains unclear about the alliance and its importance for delivering mental health care via a digital format. To employ text-based digital therapies responsibly, more insight is needed into the type and strength of the therapeutic alliance online. Methods: A systematic scoping review was performed searching four databases: Scopus, PsycINFO, Web of Science, and Wiley Online Library. A total of 23 studies were selected and data was extracted and tabulated to explore the characteristics of studies on text-based psychotherapy, measurements of the therapeutic alliance and associations of the alliance with treatment outcome. Results: The therapeutic alliance in text-based digital interventions was studied with a variety of client groups, though mostly for clients diagnosed with anxiety and/or depression issues. Treatment modalities were predominantly internet-based cognitive behavioral therapy (ICBT) and tailored platforms for distinct client groups (e.g., PTSD). Almost all treatments used asynchronous text-based communication, such as e-mails and integrated messaging functions, which were mainly used to give feedback on tasks. For measurements, a version of the Working Alliance Inventory (WAI) was used in most studies. Measurements with the WAI or WAI- short form indicated a good therapeutic alliance with a weighted mean score of 5.66 (on a scale of 1 to 7) and a weighted standard deviation of 0.84. Relations between the therapeutic alliance and treatment outcomes were mostly positive, with many studies reporting significant associations (n = 8 out of 10) or significant effects of the therapeutic alliance on treatment outcomes (n = 5 out of 6). Discussion: Our scoping review suggests that a good therapeutic alliance can be established in digital psychotherapy through text-based communication, and shows support for a positive relationship between the alliance and treatment outcomes. These findings illustrate that text-based online psychotherapy can be a responsible treatment option as far as the establishment of the therapeutic alliance is concerned. However, current measures of the therapeutic alliance might miss important aspects of the alliance in digital treatment, such as the presence of empathy or compassion.

Success Factors of Artificial Intelligence Implementation in Healthcare

Background: Artificial Intelligence (AI) in healthcare has demonstrated high efficiency in academic research, while only few, and predominantly small, real-world AI applications exist in the preventive, diagnostic and therapeutic contexts. Our identification and analysis of success factors for the implementation of AI aims to close the gap between recent years' significant academic AI advancements and the comparably low level of practical application in healthcare. Methods: A literature and real life cases analysis was conducted in Scopus and OpacPlus as well as the Google advanced search database. The according search queries have been defined based on success factor categories for AI implementation derived from a prior World Health Organization survey about barriers of adoption of Big Data within 125 countries. The eligible publications and real life cases were identified through a catalog of in- and exclusion criteria focused on concrete AI application cases. These were then analyzed to deduct and discuss success factors that facilitate or inhibit a broad-scale implementation of AI in healthcare. Results: The analysis revealed three categories of success factors, namely (1) policy setting, (2) technological implementation, and (3) medical and economic impact measurement. For each of them a set of recommendations has been deducted: First, a risk adjusted policy frame is required that distinguishes between precautionary and permissionless principles, and differentiates among accountability, liability, and culpability. Second, a "privacy by design" centered technology infrastructure shall be applied that enables practical and legally compliant data access. Third, the medical and economic impact need to be quantified, e.g., through the measurement of quality-adjusted life years while applying the CHEERS and PRISMA reporting criteria. Conclusions: Private and public institutions can already today leverage AI implementation based on the identified results and thus drive the translation from scientific development to real world application. Additional success factors could include trust-building measures, data categorization guidelines, and risk level assessments and as the success factors are interlinked, future research should elaborate on their optimal interaction to utilize the full potential of AI in real world application.

Cost-effectiveness of household contact investigation for detection of tuberculosis in Pakistan

OBJECTIVES

Despite WHO guidelines recommending household contact investigation, and studies showing the impact of active screening, most tuberculosis (TB) programmes in resource-limited settings only carry out passive contact investigation. The cost of such strategies is often cited as barriers to their implementation. However, little data are available for the additional costs required to implement this strategy. We aimed to estimate the cost and cost-effectiveness of active contact investigation as compared with passive contact investigation in urban Pakistan.

METHODS

We estimated the cost-effectiveness of 'enhanced' (passive with follow-up) and 'active' (household visit) contact investigations compared with standard 'passive' contact investigation from providers and the programme's perspective using a simple decision tree. Costs were collected in Pakistan from a TB clinic performing passive contact investigation and from studies of active contact tracing interventions conducted. The effectiveness was based on the number of patients with TB identified among household contacts screened.

RESULTS

The addition of enhanced contact investigation to the existing passive mode detected 3.8 times more cases of TB per index patient compared with passive contact investigation alone. The incremental cost was US$30 per index patient, which yielded an incremental cost of US$120 per incremental patient identified with TB. The active contact investigation was 1.5 times more effective than enhanced contact investigation with an incremental cost of US$238 per incremental patient with TB identified.

CONCLUSION

Our results show that enhanced and active approaches to contact investigation effectively identify additional patients with TB among household contacts at a relatively modest cost. These strategies can be added to the passive contact investigation in a high burden setting to find the people with TB who are missed and meet the End TB strategy goals.

Health technology assessment of telemedicine applications in Northern borders of India

BACKGROUND

Economic evaluations of health technology help to decide which interventions are to be continued and which are to be terminated. In the Armed Forces, the provision of efficient medical services requires meticulous planning for optimal utilization of scarce resources. We report a cost analysis of telemedicine and air transportation of casualties, and attempt to identify the strengths, weaknesses, opportunities and threats of telemedicine services.

METHODS

The costs incurred in telemedicine were compared with the cost of air evacuation. A qualitative assessment of telemedicine was undertaken through in-depth interviews with the hospital authorities and focused group discussions with medical officers and paramedical staff.

RESULTS

34.2% of casualties could successfully be stabilized on-site using available healthcare resources with the peripheral hospitals. 18 casualties were managed at the periphery on-site by teleconsultations each year, averting air-transportation efforts. Estimated cost savings achieved in the initial management of casualty by teleconsultation was Rs. 146,111 per case. The strengths of telemedicine are knowledge updation, faster decision making, improved pre-hospital care and improved confidence in case management.

CONCLUSION

The reduction in air efforts and remote management of casualties make a substantive case for scaling up telemedicine interventions.

The Concept of Economic Evaluation and Its Application in Thyroid Cancer Research

Economic evaluation is a type of comparative analysis between interventions in terms of both their resource use and health outcomes. Due to the good prognosis of thyroid cancer (TC), the socioeconomic burden of TC patients post-diagnosis is increasing. Therefore, economic evaluation studies focusing on TC are recommended. This study aimed to describe the concept and methods of economic evaluation and reviewed previous TC studies. Several previous studies compared the costs of interventions or evaluated recurrence, complications, or quality of life as measures of their effectiveness. Regarding costs, most studies focused on direct costs and applied hypothetical models. Cost-minimization analysis should be distinguished from simple cost analysis. Furthermore, due to the universality of the term "cost-effectiveness analysis" (CEA), several studies have not distinguished CEA from cost-utility analysis; this point needs to be considered in future research. Cost-benefit analyses have not been conducted in previous TC research. Since TC has a high survival rate and good prognosis, the need for economic evaluations has recently been pointed out. Therefore, correct concepts and methods are needed to obtain clear economic evaluation results. On this basis, it will be possible to provide appropriate guidelines for TC treatment and management in the future.

A pilot randomized controlled trial of online acceptance and commitment therapy versus compassion-focused therapy for chronic illness

Literature suggests that acceptance and commitment therapy (ACT) is effective in improving well-being and in reducing psychopathological symptoms commonly experienced by people with chronic illness (CI). Compassion-focused therapy (CFT) reduces psychological distress, especially in individuals with high levels of shame and self-criticism, but few studies have explored CFT in CI. Additionally, studies almost exclusively compared ACT and CFT with inactive controls (wait-list; treatment as usual). Also, there is an interest in developing cost-effective mental health solutions, such as low-intensity online psychological interventions. This randomized controlled trial (RCT) aimed to assess the acceptability and compare the efficacy of four-session online ACT (n = 25) and CFT (n = 24) interventions in a sample of people with CI. Results showed both interventions were acceptable, with attrition rates at post-intervention comparable to those found in similar studies (around 50%). Intention-to-treat analyses showed that participants presented significantly less illness-related shame, less uncompassionate self-responding and more valued living after the intervention, although no difference was found between conditions. Results were sustained at 3- and 6-month follow-up. Results did not find statistical differences between conditions through reliable change index (RCI). Correlation between demographics and RCI showed that, at post-intervention, younger participants presented more behavioural awareness, men presented more valued action, and participants with CI for shorter periods presented less uncompassionate self-responding and less anxiety. Results suggest that low-intensity (four sessions) online ACT and CFT are cost-effective approaches to promote mental health of individuals with CI. Results and limitations are thoroughly discussed.

Health technology assessment for digital technologies that manage chronic disease: a systematic review

OBJECTIVE

A growing number of evaluation frameworks have emerged over recent years addressing the unique benefits and risk profiles of new classes of digital health technologies (DHTs). This systematic review aims to identify relevant frameworks and synthesize their recommendations into DHT-specific content to be considered when performing Health Technology Assessments (HTAs) for DHTs that manage chronic noncommunicable disease at home.

METHODS

Searches were undertaken of Medline, Embase, Econlit, CINAHL, and The Cochrane Library (January 2015 to March 2020), and relevant gray literature (January 2015 to August 2020) using keywords related to HTA, evaluation frameworks, and DHTs. Included framework reference lists were searched from 2010 until 2015. The EUNetHTA HTA Core Model version 3.0 was selected as a scaffold for content evaluation.

RESULTS

Forty-four frameworks were identified, mainly covering clinical effectiveness (n = 30) and safety (n = 23) issues. DHT-specific content recommended by framework authors fell within 28 of the 145 HTA Core Model issues. A further twenty-two DHT-specific issues not currently in the HTA Core Model were recommended.

CONCLUSIONS

Current HTA frameworks are unlikely to be sufficient for assessing DHTs. The development of DHT-specific content for HTA frameworks is hampered by DHTs having varied benefit and risk profiles. By focusing on DHTs that actively monitor/treat chronic noncommunicable diseases at home, we have extended DHT-specific content to all nine HTA Core Model domains. We plan to develop a supplementary evaluation framework for designing research studies, undertaking HTAs, and appraising the completeness of HTAs for DHTs.

Efficacy of Online-Based Acceptance and Commitment Therapy for Chronic Pain: A Systematic Review and Meta-Analysis

Acceptance and Commitment Therapy (ACT) has been widely tested for chronic pain, with demonstrated efficacy. Nevertheless, although there is meta-analytical evidence on the efficacy of face-to-face ACT, no reviews have been performed on online ACT in this population. The aim of this meta-analysis is to determine the efficacy of online ACT for adults with chronic pain, when compared with controls. PubMed, PsycINFO, CENTRAL, and Web of Knowledge were searched for randomized controlled trials (RCTs) of online-delivered ACT for chronic pain. Effects were analyzed at post-treatment and follow-up, by calculating standardized mean differences. Online-delivered ACT was generally favored over controls (5 RCTs, N = 746). At post-treatment, medium effects for pain interference and pain acceptance, and small effects for depression, mindfulness, and psychological flexibility were found. A medium effect for pain interference and acceptance, and small effects for pain intensity, depression, anxiety, mindfulness, and psychological flexibility were found at follow-up. ACT-related effects for pain interference, pain intensity, mindfulness, and anxiety increased from post-treatment to follow-up. Nevertheless, the current findings also highlight the need for more methodologically robust RCTs. Future trials should compare online ACT with active treatments, and use measurement methods with low bias. PERSPECTIVE: This is the first meta-analytical review on the efficacy of online ACT for people with chronic pain. It comprises 5 RCTs that compared online ACT with active and/or inactive controls. Online ACT was more efficacious than controls regarding pain interference, pain intensity, depression, anxiety, mindfulness, and psychological flexibility.

Cost-Effective Analysis of the Congenital Hypothyroidism Screening Program in Sri Lanka

INTRODUCTION

Economic evaluations will determine policy decisions on any screening programs as estimates of short-term or long-term clinical and economic outcomes are analyzed through a systematic approach. This cost-effectiveness analysis was aimed to assess newborn screening for congenital hypothroidism (CH) in Sri Lanka as a important tool to allocate funds and make decisions on feasibility of new interventions with budget constraint in healthcare costs.

METHODS

The newborn screening database was retrospectively analyzed to assess key performance indicators of the program. Program cost included capital investment, sampling, forms, analytical cost, follow-up, and confirmatory costs. Treatments and management care were calculated up to the age of 75 years excluding other cost to the family for support. Total benefits to the society and disability-adjusted life-years are calculated for each year.

RESULTS

During 2019, 159 559 newborns underwent screening with over 92% coverage while 126 babies of 192 screening positive babies were confirmed as having the disease. The annual incidence of hypothyroidism was 1 in 1266 live births among the screened population. The positive predictive value of the program was 66% with a false-positive rate of <0.04% among those screened. The benefit-to-cost ratio was 3.60 with total cost of the program 98 924 300LKR with total benefit of 356 553 781LKR in 2019.

CONCLUSION

The CH screening program proved its effectiveness in both timely detecting at-risk babies as well as being appropriately effective in economic impact to society. The improved health outcomes are of utmost importance considering screening expansions and policy decisions.